P - 81795REQUEST FOR ELECTRICAL INSPECTION
'J �s� _ 21 g� Minnesota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 --
Home Duplex Apt. Bldg. Other: New ddn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques►. Enter remarks in this space a e back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T
Sign/Outline Ltg. Xfmr. r
Alarm/Remote Control � �,S''%�
Swimming Pool
I here certi that I ins the elechical insfallafion described herein on Ihe dales stated
Irri9ation Boo f� R�9M� p�
Special Inspection
Firwl � Dar� ` � Z
Investigative Fee `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_. OFFlCE USE ONLY This request wid 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Rough-in inspecfion required2 ❑ Yes lnspecfion Ofher Than RougMn: ❑ Ready iA Coll
e (You must coll Ihe inspedw when rea Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Addreu �Sheef, Box, or Route No. City Zip Code
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$ection No. Township Name or . Range No. Fire No. Coun
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(Compony Name� ¢ �� Conhacla License N�y Master lic. No.
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nhacfor or Owner Performing Installation
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y( onhac r or Owner ing Installation) Phone No. '
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY